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MRCP > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

management of raynaud’s

  • 1st line
  • 2nd line
A

1st line: calcium channel blocker eg nifedipine

2nd line: IV prostacyclin (epoprostenol) infusion

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2
Q

what suggests primary raynaud’s (2)

A

<40y old

bilateral symptoms

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3
Q

what suggests secondary raynauds (6)

A
  • unilateral onset
  • rash
  • older - >40
  • autoantibodies
  • fts suggestive of a CTD - arthritis, recurrent miscarriages, calcinosis
  • digital ulcers; chillblains
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4
Q

secondary causes of raynauds (8)

A
  • CTDs: scleroderma (most common), RA, SLE
  • Leukaemia
  • Type 1 cryogloublinaemia, cold agglutinins
  • Use of vibrating tools
  • Drugs: COCP, ergot
  • Cervical rib (extra rib above 1st rib > thoracic outlet syndrome > raynauds)
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5
Q

patterns of psoriatric arthropathy

A
  1. symmetric polyarthritis (most common: 30-40% - like RA)
  2. asymm oligoarthritis - usually hands and feet. 20-30%
  3. sacroilitis
  4. DIP joint disease
  5. arthritis mutilans
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6
Q

Xray of psoriatric arthropathy

A

often have the unusual combination of coexistence of erosive changes and new bone formation
periostitis
‘pencil-in-cup’ appearance

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7
Q

other signs of psoriatric arthritis

A

psoriatic skin lesions

periarticular disease - tenosynovitis and soft tissue inflammation resulting in:

  • enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis
  • tenosynovitis: typically of the flexor tendons of the hands
  • dactylitis: diffuse swelling of a finger or toe

nail changes: pitting, onycholysis

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8
Q

whats the first Ix to do for septic arthritis

A

synovial fluid sampling

- only dont do 1st if septic/unstable

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9
Q

abx for septic arthritis

A

IV fluclox - or clindamycin if pen allergic - for 6-12wks

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10
Q

common bacteria that cause septic arthritis

A
  • staph aureus (most common)
  • n gonorrhoea (young and sexually active)

most common site = knee

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11
Q

reactive arthritis symptoms

A

Triad of symptoms (cant see, pee or climb a tree)

Urethritis

Conjuncitivitis

Arthritis

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12
Q

reactive arthritis causes (bacteria)

A

STI (more common in men): chlamydia trachomatis

Dysentery: shigella flexneri, salmonella typhimurium, salmonella enteritidis, yersinina enterocolitica, campylobacter

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13
Q

reactive arthritis mx

A

Symptomatic: anlagesia, NSAIDs, steroid injections into the joint

Persistent disease: can use sulfasalazine, methotrexate

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14
Q

important

mx of ank spond

A

1st line: exercise + NSAIDs; physio

if persistently high disease activity despite this: anti-TNF therapy

DMARDS for RA only useful if peripheral joints involved (EG sulfasalazine)

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15
Q

XR changes seen in ank spond

A 
Plain XR: most useful Ix in diagonsis 
- Can be normal early on 
LATER
- Sacroilitis (subchrondral erosions, sclerosis) 
- Squaring of lumbar vertebrae 
- Bamboo spine  
- Syndesmophytes (ossification of outer fibres of annulus fibrosus [exterior of intervertebral disc]) 
- Apical fibrosis on CXR

If negative XR but high clinical suspicion > MRI
- Signs of early inflam involving SI joints (bone marrow oedema) confirm dx

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16
Q

paget’s disease: blood levels of calcium/phosphate/other tests

A
  • normal value of calcium, phosphate
  • high ALP

Other markers of bone turnover will be high:

  • procollagen type I N-terminal propeptide (PINP)
  • serum C-telopeptide (CTx)
  • urinary N-telopeptide (NTx)
  • urinary + serum hydroxyproline
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17
Q

paget’s disease: tx and indications for it

A

Indications for tx

  • Bone pain
  • Skull or long bone deformity
  • Fracture
  • Periarticular paget’s

Tx

  1. Bisphosphonate (oral risedronate or IV zoledronate)
  2. Calcitonin – less commonly used now
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18
Q

how to tell drug induced lupus and SLE apart

A

drug induced: dont tend to see renal or nervous system involvement.
negative Anti-ds-DNA antibodies. positive anti-histone antibodies

normal SLE: positive for dsDNA. negative for anti histone

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19
Q

dermatomyositis:

  • Abs most specific
  • Abs most common to it
A

most specific: Anti-Mi-2

most common: ANA

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20
Q

dermatomyositis fts

A 
Proximal pain and tenderness 
Heliotrope sign (violaceous rash over eyelids) 
Shawl sign (rash over upper arms, shoulders & upper back)
21
Q

dermatomyostitis tx

A

prednisolone

22
Q

pseudogout: whats seen in the joint fluid

A

weakly positively birefringent rhomboid-shaped crystals

23
Q

pseudogout RF

A

Haemochromatosis
Hyperparathyroid
Low Mg or low phosphate
Acromegaly, wilsons

24
Q

pseudogout mx

A

Aspiration of joint fluid (to excl septic arthritis)

NSAIDs or steroids (into the joint, IM or oral)

25
Q

prophyria cutanea tarda - mx

A

Chloroquine

Venesection if iron ferritin >600ng/ml

26
Q

prophyria cutanea tarda - causes

A

Inherited defect in uroprophyrinogen decarboxylase

Hepatocyte damage – alcohol, hep C, oestrogen

27
Q

porphyria cutanea tarda presentation

A

Photosensitive rash w blistering and skin fragility on face + dorsal aspect of hands

Oncholysis

Hypertrichosis (excessive hair)

Hyperpigmentation

28
Q

impetigo - tx

A

1st line: hydrogen peroxide 1% cream (for systemically well and low risk of complications)

Next options

  • Topical fusidic acid
  • If resistant to this: topical mupirocin (could be MRSA)

Extensive disease:

  • Oral fluclox
  • Pen-allergic: oral erythromycin
29
Q

bacteria that cause impetigo

A

Causes: staph aureus, strep pyogenes

30
Q

uncontrolled psoriasis and psoriatric arthritis - tried NSAIDs and steroids - what now?

A

etanercept

31
Q

what dose of steroids makes you want to offer osteoporosis prophylaxis

A

equiv of pred 7.5mg OD for 3 months

32
Q

key XR change in ank spond

A

syndesmophytes: due to ossification of outer fibers of annulus fibrosus

Radiographs may be normal early in disease, later changes include:
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
chest x-ray: apical fibrosis

33
Q

COMPRESSION OF nerve root of

  • L3
  • L4
  • L5
  • S1
A
  • L3: sensory loss over anterior thigh
  • L4: sensory loss over anterior knee
    both L3 & L4: weak quadriceps, reduced knee reflex, positive femoral stretch test
  • L5: sensory loss of dorsum/top of foot, weak foot and big toe dorsiflexion, positive sciatic nerve stretch test (reflexes intact)
  • S1: sensory loss to posterolateral leg and lateral foot, weak plantar flexion, reduced ankle reflex, positive SN stretch test
34
Q

osteogenesis imperfecta

whats the problem

A

type 1 collagen

35
Q

Abs for dermatomyositis: most sens and most spec

Abs for polymyositis

A

dermato: ana most common, anti-mi-2 most specific
poly: anti-Jo-1

36
Q

denosumab action?

A

RANK ligand inhibitor > inhibits maturation of osteoclasts

37
Q

SLE

  • most sensitive antibody?
  • most specific?
  • what Ab do they use for monitoring
  • what happens to complement?
A

· Most sensitive = ANA: 99% +ve (high sensitivity = useful rule out test, but low specificity)
· Most specific = anti-smith
○ Anti-dsDNA and anti-Smith very specific >99% but less sensitive
○ Anti-dsDNA can be used for monitoring (but not present in all pts)
C3 and C4 levels low during active disease (formation of immune complexes > consumption of complement)

38
Q

mx of RA

  • 1st line
  • 2nd line
  • 3rd line
  • whats rituximab?
  • mx of flares?
A

1st line: DMARD and short course of prednisolone
- DMARD options: methotrexate, sulfasalazine, leflunomide, hydroxychloroquine

then try another DMARD
if not good response to 2: TNF inhibitor (Etanercept, infliximab, adalimumab)

Flares: mx w steroids (oral or IM)
EXTRA: rituximab (anti-CD20)

38
Q

1st line mx of RA

A

DMARD and short course of prednisolone

39
Q

antiphospholipid syndrome

- aptt?

A

causes a paradoxical rise in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade

40
Q

azathioprine

  • can you use it in preg?
  • what common drug does it interact with?
  • SE (4)
  • how does it work pharmaceutically
A

Key bits
· Safe in pregnancy
· Can interact w allopurinol - so use lower doses of azathioprine
Notes
· SE: BM depression, N&V, pancreatitis, increased risk of non-melanoma skin cancer
· Metabolised to mercaptopurine (active: a purine analogue that inhibits purine synthesis)
May need to do TPMT (thiopurine methyltransferase test) to look for pts prone toxicity

41
Q

sulfasalazine

  • if patients are allergic to X or Y they could react to sulfasalazine
  • caution with what genetic condition?
  • pharm action
  • SE
  • preg?
A

aspirin, sulphonamides
- Caution w G6PD deficiency

Notes

- Prodrug for 5-ASA
- SE: oligospermia, SJS, pneumonitis/fibrosis, myelosuppression, Heinz-body anaemia, megaloblastic anaemia, stained contacts (can colour tears)

Details
- 5-ASA: decreases neutrophil chemotaxis + suppresses prolif of lymphocytes and pro-inflam cytokines

safe in preg and BF

42
Q

drug induced lupus causes

  • most common 2
  • less common (3)

is the damage permanent

A

Most common

  1. procainamide (used for cardiac arrhythmias)
  2. hydralazine (diuretic: high BP)

Less common

  1. isoniazid (TB)
  2. minocycline (abx)
  3. phenytoin (epilepsy)
    • Don’t get renal or nervous involvement usually
      Resolves on stopping drug
43
Q

heberden’s & bouchard’s nodes

what disease are they seen in, where are they, what are they and whats the cause

A

OA
Heberden’s nodes at the DIPJs, Bouchard’s Nodes at the PIPJs.
Painless nodes (bony swellings):
Due to osteophyte formation

44
Q

RF for osteoporosis

A

Sig RF: female, older age

RF used by major risk assessment tools such as FRAX:
	• history of glucocorticoid use
	• RA
	• alcohol excess
	• history of parental hip fracture
	• low BMI
	• current smoking

Other RF
• sedentary lifestyle
• premature menopause
• Caucasians and Asians
• endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), GH deficiency, hyperparathyroidism, DM
• multiple myeloma, lymphoma
• GI: IBD, malabsorption (e.g. Coeliac’s), gastrectomy, liver disease
• CKD
• osteogenesis imperfecta, homocystinuria

45
Q

Medications that may worsen osteoporosis (other than glucocorticoids):

A 
• SSRIs
	• antiepileptics
	• PPIs
	• glitazones
	• long term heparin therapy
aromatase inhibitors e.g. anastrozole
46
Q

osteoporosis

  • t score: what is it, values for normal/osteopenia/osteoporosis
  • z score
A

Basics
T score: based on bone mass of young reference population
T score of -1.0 means bone mass of one standard deviation below that of young reference population
Z score is adjusted for age, gender and ethnic factors

T score
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis

47
Q

ank spond comps

A 
• Apical fibrosis
	• Anterior uveitis
	• Aortic regurgitation
	• Achilles tendonitis
	• AV node block
	• Amyloidosis
	• and cauda equina syndrome
peripheral arthritis (25%, more common if female)

MRCP (16 decks)

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